2.0 Analysis 2.1 Cause of the Deck-hand Falling Overboard Under the prevailing wind and sea conditions, the vessel was rolling and pitching moderately. The rake being towed along the sea-bed could have had a damping effect, disrupting the vessel's regular motion. This motion would have been further disrupted by the snagging of the rake on the sea-bed, bringing the vessel to a sudden stop. All these reasons could account for the deck- hand losing his balance and falling overboard. 2.2 Use of Personal Flotation Devices during Fishing Operations Fishing, in general, is a high-risk occupation, and the traditional attitude of fishermen is to accept the risks involved4. As such, the impact of work conditions on safety often loses its emphasis, more so when similar situations have not had a negative impact in the past. Thus, the possibility of falling overboard from small vessels such as THE PAMELA JENELLE L., especially during adverse weather conditions, is often downplayed, in turn diminishing the acceptance of the need to wear safety clothing which could provide both thermal protection and flotation capability. In this instance, the deck-hand wore insulated coveralls but did not wear a flotation jacket. By doing so, when he fell into the sea, his ability to survive was seriously compromised. 2.3 Factors Affecting Survival The Canadian Red Cross pamphlet entitled Cold Water Survival graphically illustrates that the average predicted survival time for the average adult wearing a lifejacket and holding still while immersed in 8C water is about two hours. Because the deck-hand was not wearing a flotation device, he would have expended a great deal of energy in attempting to swim/stay afloat. This attempt would have been hindered by the additional weight of the waterlogged insulated coveralls. The resulting exhaustion in conjunction with loss of body heat due to immersion in cold water would have adversely affected his survival time. All of the above would account for the deck-hand being unable to help himself after being immersed in the sea water for about 15 minutes, which is well below the expected survival time, despite the fact that he was a good swimmer. 2.4 Lifebuoy Line Shortfall As the lifebuoy had not been fitted with a line, it could not be retrieved. As such, no subsequent attempt was possible nor was the lifebuoy available for buoyant support after the operator had grasped the deck-hand. The fitting of the lifebuoy with a line would have eliminated the need for the deck-hand to be left unattended while he was weak and vulnerable. 3.0 Conclusions 3.1 Findings The vessel was rolling and pitching moderately in moderate seas while engaged in towing a rake. The snagging of the rake on the sea-bed brought the vessel to a sudden halt, disrupting the vessel's regular motion. The deck-hand fell overboard from the open afterdeck. Neither of the crew members wore a personal flotation device nor are they required to by regulation. Clothing worn by the deck-hand did not provide buoyancy and, when wet, increased in weight and compromised the deck-hand's ability to stay afloat, hindering rescue efforts. The rapidity with which the deck-hand lost his physical strength was due to exhaustion and loss of body heat because of immersion in cold water. The lifebuoy was not fitted with the mandatory line and, following the first failed attempt, could not be retrieved for further use. The loss of the lifebuoy hampered rescue attempts and the lifebuoy was not available for buoyant support at a crucial time of the rescue. The deck-hand was lost because he was not wearing a lifejacket or a personal flotation device. 3.2 Causes The deck-hand lost his balance and fell overboard in moderate seas most probably because of the disruption in the vessel's motion due to the rake snagging on the sea-bed. Rescue attempts were hampered by the absence of a line attached to the lifebuoy; the deck-hand was subsequently lost because he was not wearing any form of a flotation device. 4.0 Safety Action 4.1 Action Taken 4.1.1 Life-saving Equipment In December 1993, a TSB Marine Safety Information (MSI) letter apprised the Canadian Coast Guard (CCG) of the fact that the heaving line required to be attached to the lifebuoy according to the Small Fishing Vessel Inspection Regulations was missing. The MSI letter raised two areas of potential safety deficiencies: CCG inspection procedures and practices and/or fishermen's diligence in the maintenance of their own safety standards perhaps due to a lack of safety awareness. In its response to the MSI letter, the CCG indicated that, during the last inspection in August 1991, THE PAMELA JENELLE L. was found to have been equipped in accordance with regulations, including the lifebuoy fitted with a line. Furthermore, the CCG believes that fishermen do not lack safety awareness; rather, there is a traditional attitude of accepting risks. Notwithstanding, the CCG stated that it is actively promoting the use of anti-exposure worksuits stressing the need for fishermen to properly maintain safety equipment and wear appropriate safety clothing.